Review of different approaches of the left recurrent laryngeal nerve area for lymphadenectomy during minimally invasive esophagectomy

The use of indocyanine green and near-infrared fluorescence in the detection of metastatic lymph nodes during oesophageal and gastric cancer resection: a systematic review and meta-analysis

BACKGROUND

Lymph node status is one of the most important prognosticating factors for patients afflicted by oesophageal cancer (OC) and gastric cancer (GC), and lymphadenectomy during surgery is therefore an essential step to ensure complete oncological resection and accurate disease staging. Intraoperative lymph node visualisation using near-infrared fluorescence (NIRF) and indocyanine green (ICG) tracing has been postulated to improve the overall lymph node yield, and to ensure the appropriate radicality, but its usefulness in the detection of metastatic lymph nodes remains unclear.

METHODS

We conducted a systematic review and meta-analysis of the relevant literature to ascertain the accuracy of ICG-guided lymphadenectomy in the detection of metastatic nodes in OC and GC. The primary outcomes were the sensitivity, specificity and diagnostic odds ratio of ICG-guided lymphadenectomy. Secondary outcomes included measurement of the effect of prior neoadjuvant chemotherapy (NAC), tumour characteristics and method of ICG administration. Summary receiver operator characteristic (SROC) curves were built to illustrate the relationship between the sensitivity of ICG and false positive rate.

RESULTS

From an initial search of 6,302 articles, 15 studies met the criteria for inclusion, incorporating 4,004 patients. The pooled sensitivity for metastatic node detection was 69.1% (95% CI 56.5-79.3%), specificity 47.4% (38.0-56.9%), and DOR 2.02 (1.40-2.92). The SROC curve for diagnostic test accuracy yielded an area under the curve of 0.60. The use of NAC adversely affected the sensitivity of ICG 74.7% [59.2-85.8%] without NAC; 52.8% [43.6-61.9%] with NAC, p = 0.018). No significant difference in efficacy was demonstrated between pathological 'T' stage, or ICG administration method.

CONCLUSION

Our findings suggest that the oncological benefits of NIRF and ICG in the context of lymphadenectomy in OC and GC are limited, and that surgeons risk omitting a significant proportion of metastatic nodes if this technique is solely relied upon.

Prediction of right recurrent laryngeal nerve lymph node metastasis in esophageal cancer based on computed tomography imaging histology

Purpose

This study aimed to identify risk factors for right recurrent laryngeal nerve lymph node (RRLNLN) metastasis using computed tomography (CT) imaging histology and clinical data from patients with esophageal squamous cell carcinoma (ESCC), ultimately developing a clinical prediction model.

Methods

Data were collected from 370 patients who underwent surgical resection at the Department of Thoracic Surgery, Zhongshan Hospital of Xiamen University, from December 2014 to December 2020. Subsequently, the venous-stage chest-enhanced CT images of the patients were imported into 3DSlicer 4.11 software, allowing for the extraction of imaging histological features. Additionally, by combining the clinical data of the patients, single- and multifactor analyses were conducted to screen the risk factors and build a predictive model in the form of a nomogram. The area under the curve (AUC) was used as a discriminant for model accuracy, while differentiation and calibration methods were applied to further evaluate the model's accuracy. Finally, the Bootstrap resampling method was employed to repeat sampling 2,000 times to draw calibration curves, while the K-fold crossvalidation method was used for the internal validation of the prediction model.

Results

The RRLNLN lymph node metastasis rate was 17.3%. Four significant factors-Maximum2DDiameterSlice, Mean, Imc1, and Dependence Entropy-were identified. Alignment diagrams were subsequently constructed, yielding an AUC of 0.938 and a C-index of 0.904 during internal validation.

Conclusion

The model demonstrates high predictive accuracy, making it a valuable tool for guiding the development of preoperative protocols.

A novel anatomical description of the esophagus: the supracarinal mesoesophagus

BACKGROUND

During thoracoscopic esophageal resection, while performing the supracarinal lymphadenectomy along the left recurrent laryngeal nerve (LRLN) from the aortic arch to the thoracic apex, we observed a not previously described bilayered fascia-like structure, serving as prolongation of the already known mesoesophagus.

METHODS

We retrospectively evaluated 70 consecutively unedited videos of thoracoscopic interventions on esophageal resections for cancer, in order to determine the validity of this finding and to describe its utility for performing a systematic and more accurate dissection of the LRLN and its adequate lymphadenectomy.

RESULTS

After mobilization of the upper esophagus from the trachea and tilting the esophagus by means of two ribbons, a bilayered fascia was observed between the esophagus and the left subclavian artery in 63 of the 70 patients included in this study. By opening the right layer, the left recurrent nerve became visualized and could be dissected free in its whole trajectory. Vessels and branches of the LRLN were divided between miniclips. Mobilizing the esophagus to the right, the base of this fascia could be found at the left subclavian artery. After dissecting and clipping the thoracic duct, complete lymphadenectomy of 2 and 4L stations could be performed. Mobilizing the esophagus in distal direction, the fascia continued at the level of the aortic arch, where it had to be divided in order to mobilize the esophagus from the left bronchus. Here, a lymphadenectomy of the aorta-pulmonary window lymph nodes (station 8) can be performed. It seems that from there the fascia continued without interruption with the previously described mesoesophagus between the thoracic aorta and the esophagus.

CONCLUSIONS

Here we described the concept of the supracarinal mesoesophagus on the left side. Applying the description of the mesoesophagus will create a better understanding of the supracarinal anatomy, leading to a more adequate and reproducible surgery.

The role of magnetic anchoring and traction technique in thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve

BACKGROUND

Dissecting lymph nodes along the left recurrent laryngeal nerve (LRLN) is the most challenging step in thoracoscopic-assisted esophagectomy. To retract the proximal esophagus in the existing lymphadenectomy methods, either a special trocar is required to insert and take out endoscopic instruments or thoracic punctures are needed to externally retract the esophageal loop. Therefore, advanced skills for esophageal traction are important to facilitate the LRLN lymphadenectomy and to reduce the incidence of trauma to the chest wall. Herein, we present the magnetic anchoring and traction technique, a novel method for LRLN lymphadenectomy during thoracoscopic esophagectomy.

METHODS

The magnetic anchoring traction system was successfully used to retract the upper thoracic esophagus and to help expose the upper mediastinum in 10 cases of thoracoscopic-assisted esophagectomy. When the external magnet was moved outside of body, the internal magnet was coupled with a magnetic force to pull the proximal esophagus to the appropriate direction, which helped to expose the LRLN and adjacent lymph nodes. The lymph nodes adjacent to the LRLN could then be dissected completely without any damage to the nerve.

RESULTS

In all surgeries, the LRLN and adjacent lymph nodes were well visualized, and the number of trocars used to pass endoscopic instruments for retraction of the proximal esophagus or the number of thoracic punctures for external traction of the esophagus during the surgery were reduced.

CONCLUSIONS

In thoracoscopic-assisted esophagectomy, the magnetic anchoring and traction technique can improve the exposure of the LRLN, facilitate LRLN lymphadenectomy, and reduce chest wall trauma.

Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis

BACKGROUND

Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure.

METHODS

The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups.

RESULTS

A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32 months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15 months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups.

CONCLUSIONS

Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.

Safety and efficacy of minimally invasive McKeown esophagectomy in 1023 consecutive esophageal cancer patients: a single-center experience

Objective

By analyzing the perioperative, postoperative complications and long-term overall survival time, we summarized the 8-year experience of minimally invasive McKeown esophagectomy for esophageal cancer in a single medical center.

Methods

This retrospective follow-up study included 1023 consecutive patients with esophageal cancer who underwent MIE-McKeown between Mar 2013 and Oct 2020. Relevant variables were collected and evaluated. Overall survival (OS) and disease-free survival (DFS) were analyzed by Kaplan–Meier method.

Results

For 1023 esophageal cancer undergoing MIE-McKeown, the main intraoperative complications were bleeding (3.0%, 31/1023) and tracheal injury (1.7%, 17/1023). There was no death occurred during operation. The conversion rate of thoracoscopy to thoracotomy was 2.2% (22/1023), and laparoscopy to laparotomy was 0.3% (3/1023). The postoperative morbidity of complications was 36.2% (370/1023), of which anastomotic leakage 7.7% (79/1023), pulmonary complication 13.4% (137/1023), chylothorax 2.3% (24/1023), and recurrent laryngeal nerve injury 8.8% (90/1023). The radical resection rate (R0) was 96.0% (982/1023), 30-day mortality was 0.3% (3/1023). For 1000 cases with squamous cell carcinoma, the estimated 3-year and 5-year overall survival was 37.2% and 17.8% respectively. In addition, neoadjuvant chemotherapy offered 3-year disease-free survival rate advantage in advanced stage patients (for stage IV: 7.2% vs. 1.8%).

Conclusions

This retrospective single center study demonstrates that MIE-McKeown procedure is feasible and safe with low perioperative and postoperative complications’ morbidity, and acceptable long-term oncologic results.

Risk factors for lymph node metastasis of the left recurrent laryngeal nerve in patients with esophageal squamous cell carcinoma

Background

The factors for left recurrent laryngeal nerve (RLN) lymph node (LN) metastasis have important guiding significance for whether the left RLN LNs should be dissected in patients with esophageal squamous cell carcinoma (ESCC), but few studies are currently available. To analyze the risk factors of LN metastasis of the left RLN area and to assess which LNs should be dissected in ESCC.

Methods

This was a retrospective study of patients who underwent McKeown minimally invasive esophagectomy (MIE) (no neoadjuvant therapy) at Tianjin Medical University Cancer Institute and Hospital (from January 2016 to December 2019). The detection of left RLN LNs using enhanced computed tomography (CT) was compared with the pathological examination.

Results

Of the total 94 participants, 43 had LN metastasis. The metastatic LNs were mainly located next to left (18.1%) and right (14.9%) RLN, and the left gastric artery (13.8%). Tumor size, LN size, tumor invasion (T stage), N stage, and tumor node metastasis (TNM) stage were associated with left RLN LNs metastasis, while LN size was the only independently associated factor [odds ratio (OR) =1.569, 95% confidence interval (CI): 0.259–1.956, P=0.0012]. The area under receiver operating characteristic (ROC) curve (AUC) reached 0.877, with 64% sensitivity and 75% specificity using a cutoff of 5.5 mm LN size.

Conclusions

The size of left RLN LN is independently associated with metastasis. Left RLN LNs >5.5 mm at CT examination are more likely to be positive and should probably be dissected.

Current Issues in Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) was first introduced in the 1990s. Currently, it is a widely accepted surgical approach for the treatment of esophageal cancer, as it is an oncologically sound procedure; its advantages when compared to open procedures, including reduction in postoperative complications, reduction in the length of hospital stay, and improvement in quality of life, are well documented. However, debates are still ongoing about the safety and efficacy of MIE. The present review focuses on some of the current issues related to conventional MIE and robot-assisted MIE based on evidence from the current literature.